Gov. Abbott approves HB 3459 fewer hassles for pre-authorization health insurers'

Staff
Alice Echo News Journal

Care for countless Texas patients will happen more quickly by reducing health insurers’ bureaucratic delays, due to a bill Gov. Greg Abbott signed to become law over the weekend. 

The Texas Medical Association (TMA) prioritized curbing health insurers’ onerous prior authorization practices this legislative session, resulting in the passage of House Bill 3459 by Rep. Greg Bonnen, MD (R-Friendswood), and Sen. Dawn Buckingham, MD (R-Lakeway), with considerable support by Sen. Jane Nelson (R-Flower Mound). The bill will allow physicians to earn a “gold card” exemption from health plans’ prior authorization review requirements for certain care – if the physician achieves a track record of enough previous approvals from insurers.

“We are excited about the gold-carding process in this law because it will provide an easier way for patients to get the care they need, and reduce the administrative burden for physicians who care for them,” said Debra Patt, MD, an Austin breast oncologist and immediate past chair of the TMA Council on Legislation.

The practice of prior authorization was started years ago by insurers to check on the medical necessity of expensive and less common care, prescriptions, and treatments; however, insurers increasingly apply it to basic and routine patient care.

Health insurers use prior authorization to scrutinize the medical services and medicine physicians order for their patients. The patient’s health insurer decides whether it wants to pay for the treatment or prescription the physician orders, and awaiting that decision often delays care. Physicians say prior authorization delays are too often unnecessary.

As an oncologist who treats cancer patients, Dr. Patt has frequently faced those approval delays.

“It interrupts the care of patients moving forward, and delays appropriate care,” she said. “Whenever I order things like imaging, it’s to evaluate response to chemotherapy, usually in patients with advanced cancer. [Waiting for authorization] can delay appropriate care decisions, sometimes by a month or more – which can have a significant impact on the care of those patients.”

Physicians whose prescriptions and treatments have been approved at least nine out of 10 times by insurers in the previous year would achieve “gold-card” exemption status. If the physician meets that threshold, the patient’s health plan should automatically approve that doctor’s prescriptions or orders for treatment. The bill also requires health insurers to ensure the person who reviews the physician’s order to be a Texas-licensed physician of the same or similar specialty as the patient’s physician.

The practice of prior authorization was started years ago by insurers to check on the medical necessity of expensive and less common care, prescriptions, and treatments; however, insurers increasingly apply it to basic and routine patient care.

Eight in 10 Texas physicians reported having to obtain prior authorization for medical procedures and even common, generic prescriptions. Four-fifths (85 percent) reported prior authorizations delayed patient care, often leading to an adverse event for their patient.

“The prior authorization burden is real,” said Dr. Patt, who looks forward to being able to provide more timely care for her cancer patients who need it, as her care approval rate would meet the 90 percent prior authorization approval threshold.

The bill takes effect in September.